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NOTIFICATION FORM – Health and other professionals
The purpose of this form is for doctors and other professionals to If you provide information to the Board honestly and
notify the Board about a doctor’s professional conduct or health. on reasonable grounds, the protection provided to
If you are a doctor notifying the Board about incidents of reportable you under legislation means you will not be held
misconduct, you can either complete this form or use it as a guide to liable, civilly, criminally or under an administrative
the information required when lodging a written notice. process, for providing that information. (Section 387-
If you are a patient or patient representative wishing to make a 390 of the Health Practitioners (Professional
complaint about a doctor, please complete the Board’s Notification Standards) Act 1999).
Form – Patients and Patient Representatives.
To assess notifications, the Board requires factual evidence. You are requested to provide relevant supporting information
with this notification form, such as:
Patient/Clinical records
Reports (e.g. Incident reports, Medico legal reports)
Records of clinical audits
Names, position title, and contact details of other people present (witnesses)
Prescriptions, certificates, drug charts
Staff rosters
Advertisements, business cards
Please note that the Board may not have access to information and documents held by Queensland Health.
Please answer all questions below (where relevant) and sign the declaration
1. Your details
Registration No.
Family Name/Surname^:
(doctors only):
Given Names^:
Postal address^:
Suburb/town^: Postcode^:
Telephone: Mobile:
Email:
2. Who is the report about?
Family Name/Surname*^: Registration No.:
Given Names*^: Date of birth: dd / mm / yyyy
Postal address:
Suburb/town: Postcode:
Telephone: Mobile:
Email:
1
^ Required field for doctors making a mandatory report about another doctor’s professional conduct or health
* Required field for all other professionals making a report to the Board
Version January 2010
3. Mandatory Reporting
Are you a doctor notifying the Board about another doctor’s reportable misconduct ?^ No Yes
reportable misconduct, by a registrant, means—
(a) conduct relating to the practice of the profession that would reasonably be considered to be sexual misconduct; or
(b) practice of the profession while intoxicated by a drug or alcohol; or
(c) practice of the profession—
(i) while affected by a physical or mental impairment, or other health condition, other than intoxication by a drug or alcohol; and
(ii) that causes, or is likely to cause, significant harm to a person receiving professional services from the registrant practising the
profession; or
(d) practice of the profession—
(i) in a way that significantly departs from accepted standards of the profession; and
(ii) that causes, or is likely to cause, harm to a person receiving professional services from the registrant practising the profession.’
4. What does your report relate to?*^
Conduct Documentation Communication Health
Eg. Eg. Eg. Eg.
Clinical assessment Medical records Insensitive/rude/ Mental health
Sexual misconduct Access to records misleading/incorrect Substance abuse
Medication Medical reports Consent Physically impairment
Inappropriate prescribing Medico-legal reports Confidentiality Other impairment
Inadequate/inappropriate Certificates Misrepresentation
treatment Clinical advertising
Assault physical/verbal
Standard of care
Patient access
Eg.
Admission Unconventional/ Other (please specify):
Breach of conditions or
Transfer Experimental
undertakings
Discharge medicine ______________________
5. What is your relationship to the doctor?
Medical colleague Treating practitioner of Employer of the doctor Allied health professional
Professional Body the doctor Manager/Supervisor of Other (please specify):
Nurse/Midwife Coroner/Police/Medicare the doctor ______________________
6. Location (if known)?
Is your report about health services provided within Queensland?*^
If no, please make a report to the relevant State or Territory. No Yes
If yes, please give details about where the incident happened.
Practice/Facility
Name^:
Street address^:
Suburb/town^: Postcode:
Telephone:
Contact person:
2
^ Required field for doctors making a mandatory report about another doctor’s professional conduct or health
* Required field for all other professionals making a report to the Board
Version January 2010
7. Patient details
Is a specific patient involved? If yes, what are the patient’s details (if known)? No Yes
Family name:
Given name/s:
Date of birth: dd / mm / yyyy
Telephone:
Email:
Do you know if the patient has made a report to the Board? No Yes Unsure
Please provide details about why the patient has not made a report? (leave blank if unknown)
Is the patient aware that you are making a report to the Board? No Yes Unsure
Do you know if other patients might be at risk?
No Yes
If yes, please provide details
8. Details of notification/health referral*^
A. If your report relates to a clinical event, what type of medical treatment did the patient receive?
B. When did you become aware of the conduct/health issue?^
C. Is anyone else able to provide further information to assist with the assessment of this
No Yes Unsure
notification?
If yes, please provide details (this may include the names of other medical/health practitioners)
1. Contact Phone No. :
2. Contact Phone No. :
3. Contact Phone No. :
D . Please provide factual details about what happened OR if you are making a health related referral please describe the
behaviours/situations that have led to the referral*^:
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^ Required field for doctors making a mandatory report about another doctor’s professional conduct or health
* Required field for all other professionals making a report to the Board
Version January 2010
9. Other
Have you lodged, or do you intend to lodge, a complaint with any other agency, i.e. Health No Yes Unsure
Quality Complaints Commission (HQCC), Queensland Police, Ethical Standards Unit (Qld.
Health)?
If yes, please give details of which agency
10. Privacy & Confidentiality
It may be necessary for us to send a copy of your report to the doctor for a response. Under s392 of the Health Practitioners
(Professional Standards) Act 1999 complaint information must not be released to anyone else unless is deemed to be in the
public interest to do so, or if the person to whom the information relates agrees to the disclosure.
The Office of the Medical Board will only use the information collected on this form to manage your notification. In accordance
with the Queensland Government’s Information Standard No 42 – Information Privacy (IS42), your personal information will
not be disclosed to any other organisation without your consent unless required by law.
 I declare that the above statements are true and correct and that all documents and supporting material lodged with
this notification form are true and correct.
Signature: Date:
11. Supporting Information
Have you attached all relevant supporting information with this form, such as:
Patient/Clinical records Incident Reports
Prescriptions, certificates, drug charts Names, position title, and contact details of other people
Staff rosters present (witnesses)
Advertisements, business cards Medico legal reports
Other
Once complete, this form can be sent via:
Email: complaints@medicalboard.qld.gov.au Mail: Medical Board of Queensland
Professional Standards Unit
GPO Box 1667
Brisbane Qld 4001
Fax: 07 3225 2645
The Board thanks you for your cooperation in completing this notification form. If you need assistance, please contact our
Client Services Officer on 07 3234 0176. The Board considers all matters raised by members of the community seriously and
all efforts are made to deal with notifications in a timely manner. This may include referring your notification to the HQCC for
resolution. The time taken may depend on the risk and complexity of the issues. For more information about the Board’s
processes, please visit the Board’s website www.medicalboard.qld.gov.au to view the Disciplinary Policy.
4
^ Required field for doctors making a mandatory report about another doctor’s professional conduct or health
* Required field for all other professionals making a report to the Board
Version January 2010
Appendix 1
166 Registrant must give notice about reportable Misconduct
(1) Subsection (2) applies if, in the practice of the profession, a registrant (the first registrant) becomes aware, or reasonably
suspects, that another registrant (the second registrant) has engaged in reportable misconduct.
(2) The first registrant must, as soon as practicable, give the board a written notice stating the following information—
(a) the first registrant’s name and address;
(b) the second registrant’s name;
(c) details about the following—
(i) the nature of the reportable misconduct;
(ii) when the reportable misconduct happened, if known by the registrant;
(iii) where the reportable misconduct happened, if known by the registrant.
Note—
A contravention of subsection (2) by a registrant is conduct forming the basis for a ground for disciplinary action
against the registrant under the Health Practitioners (Professional Standards) Act 1999, section 124(1)(f).
(3) A notice given to the board under subsection (2) is taken to be a complaint about the second registrant made under the
Health Practitioners (Professional Standards) Act 1999, part 3.
(4) Subsection (2) does not apply if the first registrant knows, or reasonably believes, that a written notice under subsection (2)
about the reportable misconduct has already been given to the Board.
(5) For subsection (1), the first registrant does not form the relevant suspicion about the second registrant in the practice of the
profession if—
(a) the first registrant—
(i) is employed or otherwise engaged by an insurer that provides professional indemnity insurance that relates to
the second registrant; and
(ii) forms the relevant suspicion as a result of a disclosure made by a person to the first registrant in the course of
legal proceedings or the provision of legal advice arising from the insurance policy; or Health and Other Legislation
Amendment Bill 2009 Page 4
(b) the first registrant forms the relevant suspicion in the course of providing advice about the reportable misconduct for
the purposes of a legal proceeding or the preparation of legal advice; or
(c) the first registrant is a lawyer and forms the relevant suspicion in the course of providing legal services to the second
registrant in relation to a legal proceeding or the preparation of legal advice in which the reportable misconduct is an
issue.
(6) In this section—
forms the relevant suspicion , about the second registrant, means becomes aware, or reasonably suspects, that the second
registrant has engaged in reportable misconduct.
harm, to a person, means any detrimental effect on the person’s physical or psychological wellbeing.’.
reportable misconduct, by a registrant, means—
(a) conduct relating to the practice of the profession that would reasonably be considered to be sexual misconduct; or
(b) practice of the profession while intoxicated by a drug or alcohol; or
(c) practice of the profession—
(i) while affected by a physical or mental impairment, or other health condition, other than intoxication by a drug or
alcohol; and
(ii) that causes, or is likely to cause, significant harm to a person receiving professional services from the registrant
practising the profession; or
(d) practice of the profession—
(i) in a way that significantly departs from accepted standards of the profession; and
(ii) that causes, or is likely to cause, harm to a person receiving professional services from the registrant practising
the profession.’.